A Critical Realist Translational Social Epidemiology Protocol for Concretising and Contextualising a "Theory of Neighbourhood Context, Stress, Depression, and the Developmental Origins of Health and Disease (DOHaD)", Sydney Australia.

BACKGROUND: We will describe here a translational social epidemiology protocol for confirming a critical realist "Theory of Neighbourhood Context, Stress, Depression, and the Developmental Origins of Health and Disease (DOHaD). The approach will include the concretising and contextualising of the above causal theory into programme theories for child and adolescent interventions that aim to break intergenerational cycles of disadvantage and poor life outcomes. In undertaking this work we seek to advance realist translational methodology within the discipline of applied perinatal and paediatric social epidemiology. THEORY AND METHODS: The research settings are in metropolitan Sydney. The design will be a longitudinal, multi-level, mixed method realist evaluation of applied programme interventions that seek to break the intergeneration cycle of social disadvantage and poor child health and developmental outcomes. The programme of research will consist of three components: 1) Operationalisation of the theory and designing of programme initiatives for implementation; 2) Evaluation of the translated programme and implementation theory using Theory of Change and critical realist evaluation; and 3) Theory Testing of realist hypotheses using both intensive and extensive critical realist research methods including realist structural modelling. DISCUSSION: The proposed programme of research will assist in translating empirical explanatory theory building to theory driven interventions. The research will be situated in socially disadvantaged regions of Sydney where the local child and family inter-agencies will collaborate to design and implement new initiatives that address significant disparities in childhood development and adolescent outcomes attributed to neighbourhood circumstances, family stress and intergenerational cycles of disadvantage and poor mental health.

Designing Initiatives for Vulnerable Families: From Theory to Design in Sydney, Australia.

INTRODUCTION: Intergenerational cycles of poverty, violence and crime, poor education and employment opportunities, psychopathology, and poor lifestyle and health behaviours require innovative models of health care delivery to break them. We describe a programme of research informed service development targeting vulnerable families in inner metropolitan Sydney, Australia that is designed to build and confirm a "Theory of Neighbourhood Context, Stress, Depression, and the Developmental Origins of Health and Disease (DOHaD)". We describe the development of an intervention design and business case that drew on earlier realist causal and programme theoretical work. METHODS: Realist causal and programme theory were used to inform the collaborative design of initiatives for vulnerable families. The collaborative design process included: identification of desirable and undesirable outcomes and contextual factors, consultation forums, interagency planning, and development of a service proposal. RESULTS: The design elements included: perinatal coordination, sustained home visiting, integrated service model development, two place-based hubs, health promotion and strengthened research and analysis capability. CONCLUSIONS: We demonstrate here the design of interventions for vulnerable families in Sydney utilising translational research from previous realist causal and program theory building to operational service design. We have identified the importance of our earlier analysis of underlying causal mechanisms and related programme mechanisms for identifying the elements for the full intervention design. The application of theory added rigour to the design of the integrated care initiatives. In applying the theory to the local situation the analysis took into account: the role of the local agencies; evidence of program effectiveness; determinants and outcomes for local children and their families; the current deployment of service resources; and insights from front-line staff and interagency partners.

Realist theory construction for a mixed method multilevel study of neighbourhood context and postnatal depression.

BACKGROUND: We have recently described a protocol for a study that aims to build a theory of neighbourhood context and postnatal depression. That protocol proposed a critical realist Explanatory Theory Building Method comprising of an: (1) emergent phase, (2) construction phase, and (3) confirmatory phase. A concurrent triangulated mixed method multilevel cross-sectional study design was described. The protocol also described in detail the Theory Construction Phase which will be presented here. METHODS: The Theory Construction Phase will include: (1) defining stratified levels; (2) analytic resolution; (3) abductive reasoning; (4) comparative analysis (triangulation); (5) retroduction; (6) postulate and proposition development; (7) comparison and assessment of theories; and (8) conceptual frameworks and model development. THEORY CONSTRUCTION: The stratified levels of analysis in this study were predominantly social and psychological. The abductive analysis used the theoretical frames of: Stress Process; Social Isolation; Social Exclusion; Social Services; Social Capital, Acculturation Theory and Global-economic level mechanisms. Realist propositions are presented for each analysis of triangulated data. Inference to best explanation is used to assess and compare theories. A conceptual framework of maternal depression, stress and context is presented that includes examples of mechanisms at psychological, social, cultural and global-economic levels. Stress was identified as a necessary mechanism that has the tendency to cause several outcomes including depression, anxiety, and health harming behaviours. The conceptual framework subsequently included conditional mechanisms identified through the retroduction including the stressors of isolation and expectations and buffers of social support and trust. CONCLUSION: The meta-theory of critical realism is used here to generate and construct social epidemiological theory using stratified ontology and both abductive and retroductive analysis. The findings will be applied to the development of a middle range theory and subsequent programme theory for local perinatal child and family interventions.

Being alone and expectations lost: a critical realist study of maternal depression in South Western Sydney.

The study reported here is part of a critical realist multilevel study. It seeks to identify and explain complex perinatal contextual social and psychosocial mechanisms that may influence the developmental origins of health and disease, with a focus on the role of postnatal depression. The aims of the greater study are to: (1) describe the phenomenon of postnatal depression in South Western Sydney; and (2) identify mechanisms that would add to our understanding of the psycho-social causes of maternal depression. This paper will move beyond our previous quantitative descriptions of individual-level predictors of depressive symptoms by seeking the views of local mothers and practitioners, to explain the mechanisms that might be involved. The study was set in South Western Sydney, New South Wales, Australia. An Explanatory Theory Building Method was used. The previously reported quantitative study was a non-linear principal component analysis and logistic regression study of 15,389 months delivering in 2002 and 2003. This intensive qualitative study used open coding of interviews, of seven practitioners and three naturally occurring mothers groups, to enable maximum emergence. The theoretical concepts identified were: attachment and nurturing, infant temperament, unplanned pregnancy and sole parenthood, support for mothers, access to services, stress, financial hardship, isolation and marginalisation, mothers' "loss of control" and "power", and expectations and dreams. Being alone and expectations lost emerged as possible triggers of stress and depression for mothers. These findings might also apply to others who have their dreams shattered during life's transitions. In these situations social and cultural context can either nurture and support or marginalise and isolate. The challenge for policy and practice is to support mothers and their partners during the transition to parenthood within a challenging social and material context.

Bayesian hierarchical spatial regression of maternal depressive symptoms in South Western Sydney, Australia.

BACKGROUND: There is increasing interest in the role played by maternal depression in mediating the effects of adversity during pregnancy and poor infant outcomes. There is also increasing evidence from multilevel regression studies for an association of area-level economic deprivation and poor individual mental health. The purpose of the study reported here is to explore the spatial distribution of postnatal depressive symptoms in South Western Sydney, Australia, and to identify covariate associations that could inform subsequent multilevel studies. METHODS: Mothers (n = 15,389) delivering in 2002 and 2003 were assessed at 2-3 weeks after delivery for risk factors for depressive symptoms. The individual-level binary outcome variables were Edinburgh Depression Scale (EDS) >9 and >12. The association between social, demographic and ecological factors and aggregated outcome variables were investigated using exploratory factor analysis and multivariate hierarchical Bayesian spatial regression. Relative risks from the final EDS >12 regression model were mapped to visualise the contribution from explanatory covariates and residual components. RESULTS: The exploratory factor analysis identified six factors: neighbourhood adversity, social cohesion, health behaviours, housing quality, social services, and support networks. Variables associated with neighbourhood adversity, social cohesion, social networks, and ethnic diversity were consistently associated with aggregated depressive symptoms. Measures of social disadvantage, lack of social cohesion and lack of social capital were associated with increased depressive symptoms. The association with social disadvantage was not significant when controlling for ethnic diversity and social capital. CONCLUSIONS: The findings support the theoretical proposition that neighbourhood adversity causes maternal psychological distress and depression within the context of social buffers including social networks, social cohesion, and social services. The finding have implications for the distribution of health services including early nurse home visiting which has recently been confirmed to be effective in preventing postnatal depression.

Realist explanatory theory building method for social epidemiology: a protocol for a mixed method multilevel study of neighbourhood context and postnatal depression.

A recent criticism of social epidemiological studies, and multi-level studies in particular has been a paucity of theory. We will present here the protocol for a study that aims to build a theory of the social epidemiology of maternal depression. We use a critical realist approach which is trans-disciplinary, encompassing both quantitative and qualitative traditions, and that assumes both ontological and hierarchical stratification of reality. We describe a critical realist Explanatory Theory Building Method comprising of an: 1) emergent phase, 2) construction phase, and 3) confirmatory phase. A concurrent triangulated mixed method multilevel cross-sectional study design is described. The Emergent Phase uses: interviews, focus groups, exploratory data analysis, exploratory factor analysis, regression, and multilevel Bayesian spatial data analysis to detect and describe phenomena. Abductive and retroductive reasoning will be applied to: categorical principal component analysis, exploratory factor analysis, regression, coding of concepts and categories, constant comparative analysis, drawing of conceptual networks, and situational analysis to generate theoretical concepts. The Theory Construction Phase will include: 1) defining stratified levels; 2) analytic resolution; 3) abductive reasoning; 4) comparative analysis (triangulation); 5) retroduction; 6) postulate and proposition development; 7) comparison and assessment of theories; and 8) conceptual frameworks and model development. The strength of the critical realist methodology described is the extent to which this paradigm is able to support the epistemological, ontological, axiological, methodological and rhetorical positions of both quantitative and qualitative research in the field of social epidemiology. The extensive multilevel Bayesian studies, intensive qualitative studies, latent variable theory, abductive triangulation, and Inference to Best Explanation provide a strong foundation for Theory Construction. The study will contribute to defining the role that realism and mixed methods can play in explaining the social determinants and developmental origins of health and disease.

Immigrant maternal depression and social networks. A multilevel Bayesian spatial logistic regression in South Western Sydney, Australia.

The purpose is to explore the multilevel spatial distribution of depressive symptoms among migrant mothers in South Western Sydney and to identify any group level associations that could inform subsequent theory building and local public health interventions. Migrant mothers (n=7256) delivering in 2002 and 2003 were assessed at 2-3 weeks after delivery for risk factors for depressive symptoms. The binary outcome variables were Edinburgh Postnatal Depression Scale scores (EPDS) of >9 and >12. Individual level variables included were: financial income, self-reported maternal health, social support network, emotional support, practical support, baby trouble sleeping, baby demanding and baby not content. The group level variable reported here is aggregated social support networks. We used Bayesian hierarchical multilevel spatial modelling with conditional autoregression. Migrant mothers were at higher risk of having depressive symptoms if they lived in a community with predominantly Australian-born mothers and strong social capital as measured by aggregated social networks. These findings suggest that migrant mothers are socially isolated and current home visiting services should be strengthened for migrant mothers living in communities where they may have poor social networks.

Why are advance care planning decisions not implemented? Insights from interviews with Australian general practitioners.

BACKGROUND: Advance care planning (ACP) is thought to enhance patient autonomy and improve end-of-life care. However, there is evidence that when patients engage in ACP, the resultant plans are often not implemented. This has been attributed to either nonadherence by health professionals or inadequacies in ACP such as inaccessibility of the plans, plans providing ambiguous or conflicting instructions, and inappropriate focus on the completion of documents rather than communication. However, it is not known whether these postulated reasons are consistent with the experiences and views of health care professionals providing end-of-life care in the community. OBJECTIVE: Our aim was to explore the perspectives of general practitioners (GPs) on factors influencing the implementation of ACPs. METHODS: We conducted semi-structured, open-ended interviews of a purposive sample of 17 Australian GPs. Interview transcripts were analysed using constructionist grounded theory utilizing NVivo 9 software. RESULTS: Factors that were considered to have an important influence on the implementation of ACPs include: ACP factors such as form, legal standing, accessibility, clarity, currency, and specificity; illness factors such as quality of life, function, diagnosis, prognosis, and prognostic certainty; family factors such as family attitudes to ACP and different conceptualizations on whether care is provided to individuals or to a family unit; and organizational and care setting factors such as health care facility's attitudes and policies in relation to end-of-life care. CONCLUSIONS: Problems in implementation of ACPs are multifactorial and not necessarily due to deliberate nonadherence by health professionals. Potential solutions to improve the clinical impact of ACP are discussed.

Clusters of maternal depressive symptoms in South Western Sydney, Australia.

The purpose of this study is to explore the spatial distribution of perinatal depressive symptoms in South Western Sydney, Australia, and to identify any clusters that could inform subsequent qualitative, ecological and multilevel studies and local public health interventions. A routine survey of mothers with newborn infants was commenced in 2000. The survey included the Edinburgh Postnatal Depression Scale (EPDS). Mothers (n=15,389) delivering in 2002 and 2003 were assessed at 2-3 weeks after delivery for risk factors for depressive symptoms. The binary outcome variables were EPDS>9 and EPDS>12. EPDS>9 and EPDS>12 was mapped for 101 suburbs using likelihood standardised morbidity ratios (SMRs) and Bayesian log-normal models with conditional autoregressive (CAR) components. Open domain software SaTScan™ was used to test for the presence of clusters. The Bayesian methods identified clusters of depressive symptoms in north-east, north-west and southern areas of the study region. The northern clusters were statistically significant using SaTScan™. There were two high risk clusters of EPDS>9 (radius 4.3 and 5.6 km, both p<0.001) and two high risk clusters of EPDS>12 (radius 1.8 km p=0.003 and radius 3.97 km p=0.012). The clusters were in regions known to be socially disadvantaged and with high rates of non-English speaking migrants. The study findings will be used to inform future qualitative and epidemiological research, and to plan interagency early intervention services for women, children and their families.

Advance care planning and interpersonal relationships: a two-way street.

BACKGROUND: Advance care planning (ACP) has been gaining prominence for its perceived benefits for patients in enhancing patient autonomy and ensuring high-quality end-of-life-care. Moreover, it has been postulated that ACP has positive effects on families and health professionals and their relationship with the patient. However, there is a paucity of studies examining the views of GPs on this issue. OBJECTIVE: To explore GP views on the impact that ACP has on interpersonal relationships among those involved in the patient's care. METHOD: Semi-structured, open-ended interviews of a purposive sample of 17 GPs. Interview transcripts were analysed using constructionist grounded theory methodology with QSR NVivo 9 software. RESULTS: ACP was seen as having both positive and negative impacts on interpersonal relationships. It was thought to enhance family relationships, help resolve conflicts between families and health professionals and improve trust and understanding between patients and health professionals. Negatively, it could take the family's attention away from patient care. The link between ACP and interpersonal relationships was perceived to be bidirectional-the nature of interpersonal relationship that patients have with their families and health professionals has a profound impact on what form of ACP is likely to be useful. CONCLUSION: Our study highlights the importance that GPs place on the link between ACP and the patient's interpersonal context. This has implications on how ACP is conducted in primary care settings that are considerably different from other care settings in their emphasis on continuity of care and long-term nature of relationships.

Relationship of postnatal depressive symptoms to infant temperament, maternal expectations, social support and other potential risk factors: findings from a large Australian cross-sectional study.

BACKGROUND: From 2000 a routine survey of mothers with newborn infants was commenced in South Western Sydney. The survey included the Edinburgh Postnatal Depression Scale (EPDS). The aim of the study was to determine the prevalence and risk factors for postnatal depressive symptoms in women living in metropolitan Sydney, Australia. METHODS: Mothers (n=15,389) delivering in 2002 and 2003 were assessed at 2-3 weeks after delivery for risk factors for depressive symptoms. The binary outcome variables were EPDS>9 and >12. Logistic regression was used for the multivariate analysis. RESULTS: The prevalence of EPDS>9 was 16.93 per 100 (95% CI: 16.34 to 17.52) and EPDS>12 was 7.73 per 100 (95% CI: 6.96 to 7.78). The final parsimonious logistic regression models included measures of infant behaviour, financial stress, mother's expectation of motherhood, emotional support, sole parenthood, social support and mother's country of birth. CONCLUSIONS: Infant temperament and unmet maternal expectations have a strong association with depressive symptoms with implications for the design of both preventative and treatment strategies. The findings also support the proposition that social exclusion and social isolation are important determinants of maternal depression.

Uptake and implementation of Advance Care Planning in Australia: findings of key informant interviews.

OBJECTIVE: Advance Care Planning (ACP) has an important role in enhancing patient autonomy and guiding end-of-life care. However, there is low uptake of ACP and evidence that advance care plans are often not implemented. We explored these issues in interviews with expert clinicians and representatives of key stakeholder organisations with interest in end-of-life care. METHOD: Qualitative descriptive study of semi-structured telephone interviews with 23 participants. RESULTS: Participants thought that the low uptake of ACP in Australia is a result of inadequate awareness, societal reluctance to discuss end-of-life issues, and lack of health professionals' involvement in ACP. Problems in implementation of advance care plans were thought to be a result of problems in accessing ACP documents; interpreting written documents; making binding decisions for future unpredictable situations; and paternalistic attitudes of health professionals and families. Participants had different perspectives on how advance care plans should be implemented, with some believing in strict implementation, whereas others believed in a more flexible approach. IMPLICATIONS: Low uptake and poor implementation of advance care plans may be addressed by (1) increasing community awareness; (2) encouraging health professional involvement; and (3) system-wide implementation of multi-faceted interventions. A patient-centred approach to ACP is required to resolve the differences in views on how advance care plans should be implemented.

A rapid equity focused health impact assessment of a policy implementation plan: An Australian case study and impact evaluation.

BACKGROUND: Equity focused health impact assessments (EFHIAs), or health equity impact assessments, are being increasingly promoted internationally as a mechanism for enhancing the consideration of health equity in the development of policies, programs and projects. Despite this there are relatively few examples of examples of completed EFHIAs available. This paper presents a case study of a rapid EFHIA that was conducted in Australia on a health promotion policy implementation plan. It briefly describes the process and findings of the EFHIA and evaluates the impact on decision-making and implementation. METHODS: The rapid EFHIA was undertaken in four days, drawing on an expert panel and limited review of the literature. A process evaluation was undertaken by email one month after the EFHIA was completed. An impact evaluation was undertaken two years later based on five semi-structured interviews with members of the EFHIA working group and policy officers and managers responsible for implementing the plan. A cost estimation was conducted by the EFHIA working group. FINDINGS: The EFHIA made both general and specific recommendations about how the health equity impacts of the policy implementation plan could be improved. The impact evaluation identified changes to development and implementation that occurred as a result of the EFHIA, though there was disagreement about the extent to which changes could be attributed solely to the EFHIA. Those responsible considered the recommendations of the EFHIA in the next versions of their ABHI implementation plans. Factors that influenced the impact of the EFHIA included consolidating understandings of equity, enabling discussion of alternatives, and differing understandings of the purpose of the EFHIA. The EFHIA cost US$4,036 to undertake. CONCLUSIONS: This EFHIA was conducted in a short timeframe using relatively few resources. It had some reported impacts on the development of the implementation plan and enhanced overall consideration of health equity. This case highlights some of the factors and preconditions that may maximise the impact of future EFHIAs on decision-making and implementation.

An exploration of how clinician attitudes and beliefs influence the implementation of lifestyle risk factor management in primary healthcare: a grounded theory study.

BACKGROUND: Despite the effectiveness of brief lifestyle intervention delivered in primary healthcare (PHC), implementation in routine practice remains suboptimal. Beliefs and attitudes have been shown to be associated with risk factor management practices, but little is known about the process by which clinicians' perceptions shape implementation. This study aims to describe a theoretical model to understand how clinicians' perceptions shape the implementation of lifestyle risk factor management in routine practice. The implications of the model for enhancing practices will also be discussed. METHODS: The study analysed data collected as part of a larger feasibility project of risk factor management in three community health teams in New South Wales (NSW), Australia. This included journal notes kept through the implementation of the project, and interviews with 48 participants comprising 23 clinicians (including community nurses, allied health practitioners and an Aboriginal health worker), five managers, and two project officers. Data were analysed using grounded theory principles of open, focused, and theoretical coding and constant comparative techniques to construct a model grounded in the data. RESULTS: The model suggests that implementation reflects both clinician beliefs about whether they should (commitment) and can (capacity) address lifestyle issues. Commitment represents the priority placed on risk factor management and reflects beliefs about role responsibility congruence, client receptiveness, and the likely impact of intervening. Clinician beliefs about their capacity for risk factor management reflect their views about self-efficacy, role support, and the fit between risk factor management ways of working. The model suggests that clinicians formulate different expectations and intentions about how they will intervene based on these beliefs about commitment and capacity and their philosophical views about appropriate ways to intervene. These expectations then provide a cognitive framework guiding their risk factor management practices. Finally, clinicians' appraisal of the overall benefits versus costs of addressing lifestyle issues acts to positively or negatively reinforce their commitment to implementing these practices. CONCLUSION: The model extends previous research by outlining a process by which clinicians' perceptions shape implementation of lifestyle risk factor management in routine practice. This provides new insights to inform the development of effective strategies to improve such practices.

Explaining the variation in the management of lifestyle risk factors in primary health care: a multilevel cross sectional study.

BACKGROUND: Despite evidence for the effectiveness of interventions to modify lifestyle behaviours in the primary health care (PHC) setting, assessment and intervention for these behaviours remains low in routine practice. Little is known about the relative importance of various determinants of practice.This study aimed to examine the relative importance of provider characteristics and attitudes, patient characteristics and consultation factors in determining the rate of assessment and intervention for lifestyle risk factors in PHC. METHODS: A prospective audit of assessment and intervention for lifestyle risk factors was undertaken by PHC nurses and allied health providers (n = 57) for all patients seen (n = 732) over a two week period. Providers completed a survey to assess key attitudes related to addressing lifestyle issues. Multi-level logistic regression analysis of patient audit records was undertaken. Associations between variables from both data sources were examined, together with the variance explained by patient and consultation (level 1) and provider (level 2) factors. RESULTS: There was significant variance between providers in the assessment and intervention for lifestyle risk factors. The consultation type and reason for the visit were the most important in explaining the variation in assessment practices, however these factors along with patient and provider variables accounted for less than 20% of the variance. In contrast, multi-level models showed that provider factors were most important in explaining the variance in intervention practices, in particular, the location of the team in which providers worked (urban or rural) and provider perceptions of their effectiveness and accessibility of support services. After controlling for provider variables, patients' socio-economic status, the reason for the visit and providers' perceptions of the 'appropriateness' of addressing risk factors in the consultation were all significantly associated with providing optimal intervention. Together, measured patient consultation and provider variables accounted for most (80%) of the variation in intervention practices between providers. CONCLUSION: The findings highlight the importance of provider factors such as beliefs and attitudes, team location and work context in understanding variations in the provision of lifestyle intervention in PHC. Further studies of this type are required to identify variables that improve the proportion of variance explained in assessment practices.

Health impact assessment and urbanisation. Lessons from the NSW HIA Project.

Health impact assessment (HIA) can ensure that health is a core element of sustainable urban planning. Based on the experience of the NSW HIA Project, we discuss the current strengths of HIA and challenges facing it as an urban sustainability tool across five areas: the use of evidence; integrating HIA with environmental impact assessments; including consideration of equity; recognising wider determinants of health; and building capacity.

Building health impact assessment capacity as a lever for healthy public policy in urban planning.

Building capacity to improve health through applying health impact assessment (HIA) increases the range of people, organisations and communities who are able to address health problems and, in particular, the problems that arise out of social inequity and social exclusion. To achieve this, a range of strategies is required across the areas of organisational development, workforce development, resource allocation, leadership and partnerships. A conceptual framework to guide understanding of capacity building evolved during a three-year capacity building project that supported the implementation of HIA. This is also applicable to the broader agenda of healthy public policy.

Multidisciplinary care plans for diabetes: how are they used?

OBJECTIVE: To understand how multidisciplinary care plans are being used in the management of patients with diabetes, and to explore the role of collaboration in care planning. DESIGN: Grounded theory interview study. SETTING: Primary care, June 2005 to October 2006. PARTICIPANTS: Thirty-eight people from three New South Wales Divisions of General Practice: 19 general practitioners, eight diabetes-related allied health providers, two endocrinologists, and nine adults with type 2 diabetes. Sampling was purposeful then theoretical. RESULTS: GPs use care plans to organise clinical care and help patients access allied health providers. Written plans are used to educate patients about their care and to motivate change. GPs rarely discuss care plans with other providers, and providers are unlikely to change their approach to patients on the basis of care plans. Patients do not expect to participate in care planning. CONCLUSIONS: Care planning may increase evidence-based multidisciplinary care for patients with diabetes, but it rarely results in genuine collaboration between providers and patients. This suggests a difference may exist between Australian policymakers' and providers' definitions of patients with complex needs. Care plans could facilitate patient self-management by including more personalized information. Further research is needed to clarify which patients would benefit from a truly collaborative approach to their care.

Strengthening the effectiveness of 'whole of government' interventions to break the cycle of violence in disadvantaged communities.

'Whole of government' interventions are increasingly being used in disadvantaged communities to improve safety and break the cycle of violence. This paper draws on learning from the evaluation of two whole of government interventions in western Sydney that arose in response to community violence and extensive property damage. Methods for strengthening program logic and overcoming differences in perspective are outlined.